Progressive Democrats made headlines this week after unveiling a new “Medicare for all” plan. But what exactly does that moniker mean?
Well, it depends on who you ask.
The bill introduced Wednesday morning, led by Rep. Pramila Jayapal of Washington and backed by dozens of other Democrats, would transition the entire U.S. health system into a single-payer structure over the course of two years.
But it's just the latest in a trove of approaches floated or derided by politicians in their aim to expand coverage in Medicare—or even Medicaid—as “Medicare for all.”
“People can mean a lot of different things when they say ‘Medicare for all,’” Jack Hoadley, Ph.D., a health policy analyst at the Georgetown Health Policy Institute and an expert on Medicare, told FierceHealthcare. That includes everything from potential buy-ins, or the revival of the public option post-Affordable Care Act.
“It starts out as a symbolic statement," he said.
Trying to get it all straight? Here’s a primer on the differing definitions of “Medicare for all”—and where those policies stand today.
Government-run single-payer healthcare
The term “Medicare for all” was arguably popularized on the 2016 campaign trail by Sen. Bernie Sanders, I-Vt., who pushed for a single-payer system during the primaries. Since then, other versions of the proposal have emerged with the same concept, including one backed by Sanders himself.
The latest “Medicare for all” push is in the mix. Jayapal’s bill would transition the entire healthcare system in a government-run single-payer model, eliminating private insurance and federal programs outside of Medicare in the process. Jayapal’s proposal would move to this model over the course of two years and suggests generous benefits—including for long-term care—with no deductibles or copayments.
We cover EVERYONE. Not just children, not just seniors, not just healthy people. Health care is a hunan right. Whether you are rich or poor, you deserve the same quality of health care.— Rep. Pramila Jayapal (@RepJayapal) February 27, 2019
“Is this a bold, ambitious plan? Damn right, it is,” Jayapal said at a press conference to mark the bill’s introduction. “Because it has to be.”
Sanders’ initial plan is similar, though he calls for a four-year transition to a single-payer approach and did not include coverage for long-term services.
Support for a single-payer system of some kind has gained steam with some physicians and has been a major focus of National Nurses United, the country’s largest union of registered nurses. A 2017 survey found that 56% of physicians back single-payer, though some have expressed concern about reduced income, particularly if a single-payer system is built on Medicare rates.
Not all providers are on board, however. Federation of American Hospitals CEO Chip Kahn blasted the plan, warning that it would be a “massive disruption” in patient care.
Tom Nickels, American Hospital Association executive vice president for government relations and public policy, said in a statement that the plan would "impede our shared goals" of expanded coverage and lower costs.
"The government can be an unreliable business partner, as we just witnessed with the longest partial government shutdown in our nation’s history," Nickels said. "Congress also has a history of slashing provider payments for government health programs to meet its budgetary goals."
An approach in which the government ensures there is universal insurance coverage is popular—about 70% of voters backed it in a recent poll from The Hill—but it does lose traction with some people who back private insurance. (Just 13% of respondents to that poll supported this approach.)
Medicare buy-in plans
Some policymakers are seeking to pump the brakes on fully upending the existing health system while still working under a “Medicare for all” banner—and thus back a buy-in option for certain demographics.
Democrats introduced the Medicare 50 plan earlier this month, which would allow people aged 50 and over to buy in to Medicare coverage. The bill’s sponsors, led by Sen. Debbie Stabenow of Michigan, say premiums would cover the cost of care in the expansion population and that it would also lead to lower costs for younger people, as older people moved into the Medicare risk pool.
The plan was denounced by wary insurers, who say it’s a “slippery slope” to single-payer. David Merritt, executive vice president of public affairs and strategic initiatives at America’s Health Insurance Plans, told FierceHealthcare that healthcare can’t be viewed as one-size-fits-all.
“Instead of taking away the coverage that works for them today, let’s focus on protecting and improving what’s working and fixing what’s not,” Merritt said.
Hoadley said that debate on a Medicare buy-in approach stretches back to the Clinton administration, and it’s a popular middle-of-the-road way to boost access to coverage within existing systems.
One approach is splitting the two Medicare populations, so that buy-in beneficiaries don’t cause too much of a stir within Medicare pricing.
“Generally thought of as a way to do it is to put those people in separate box,” he said.
Revival of the public option
A public option, or government-backed insurance policy made available on the ACA exchanges, was a cornerstone of the debate around the healthcare law. But it ultimately missed the cut.
Hoadley said some approaches to this amount to a “Medicare-lite” that would be available for people to purchase during open enrollment. The plan would not replace but compete with private insurers offering coverage on the exchanges already.
A bill co-sponsored by 2020 Democratic hopefuls Sens. Cory Booker and Kamala Harris would have brought the public option back.
As the existing infrastructure for the exchange is already in place, a public option would be one of the simpler approaches to launch, too, Hoadley said.
‘Medicaid for all’?
Some have touted further expanding Medicaid as a more effective alternative to a “Medicare for all” approach. A number of states are eyeing potential buy-ins for their Medicaid programs, and building off Medicaid allows for an adaptable baseline to fit different populations.
For example, a public option could be built off of Medicaid and not Medicare.
“States and some policymakers federally could use Medicaid as a platform to provide an option on the exchanges,” Hoadley said. “There are other sorts of ways to use Medicaid as a springboard to more public sector coverage.”
A hybrid of additional options in Medicare and Medicaid is also a possibility, which could harness the most effective applications of both plans.
For one, a clear picture of the cost. Jayapal’s bill does not come with cost estimates attached, and skeptics have criticized Sanders for limited cost details in his legislation.
There is heated debate but limited research on the cost of a single-payer system. A report (PDF) from the Mercatus Center at George Mason University, a libertarian think tank, projected costs of about $32.6 trillion over the first 10 years of a “Medicare for all” approach based on Sanders’ bill.
However, Sanders and other supporters took that as a win, as the cost is actually $2 trillion less than overall healthcare costs are estimated to be over that same window under our current system.
Hoadley said that as many of these Medicare expansion proposals are nebulous and light on specifics, policymakers will have to account for a number of factors in today’s Medicare market if they want to move forward. Many people enrolled in traditional Medicare, for example, have supplemental plans of various kinds—Medicaid or private coverage—to mitigate out-of-pocket costs.
Ensuring cost management is feasible should be top of mind as these plans evolve, he said. Plus, about a third of Medicare beneficiaries are enrolled in a private Medicare Advantage plan, according to the Kaiser Family Foundation, and these plans are popular with members and enjoy bipartisan political support.
“It’s an option, and you could consider logically places it fits,” he said.